Op-Ed, Board Certification

ABEM Board Certification Changes: What You Need to Know

Summary
Earlier this year, the American Board of Emergency Medicine (ABEM) officially announced a new board certification process that will affect all EM board applicants taking their certifying exam in January 2026 and beyond.

Virtual “oral boards,” or the ABEM Oral Certification Exam (OCE), will be replaced with a new multicomponent exam at the AIME assessment center in Raleigh, NC. The exam components announced thus far include:

  • Clinical cases with examiners
  • Clinical decision-making assessments
  • Simulation cases with standardized patients and procedure competency evaluation

According to ABEM, this exam is designed to more appropriately reflect applicants’ clinical training received in residency, and candidates should “be able to walk out of shift and into the exam” without the need for board-specific preparation.

Current Certification Process
The vast majority (98%) of EM residents apply to become board-certified emergency physicians through ABEM.1,2 As of the writing of this article, board certification is a 3-step process in which candidates must:

  1. Apply for certification, typically in the last year of residency
  2. Pass the 305 multiple-choice question Qualifying Exam (QE), which can be taken at any of the 200 Pearson-Vue testing centers across the United States3
  3. Pass the OCE, which is held on a virtual platform4

Historically, the OCE has been a 7-case exam consisting of 5 clinical cases and 2 structured interview cases. The cited exam goal is to test applicants’ clinical knowledge, workup selection, and case management ability, in addition to clinical thought process, empathy, and more.5

Notably, the OCE went virtual in December 2020 ​​to adapt to COVID-19 pandemic-related travel and quarantine restrictions, with the purpose of preventing profound certification delays.6,7 Even after COVID-19 restrictions were lifted, the OCE’s virtual format continued.

Virtual testing has allowed candidates the flexibility to take the exam in a quiet, distraction-free environment, as long as they have a secure and reliable internet connection — though there are a limited number of testing periods available annually.

The OCE currently costs $1,255, which ABEM says is one of the lowest oral exam costs among all medical specialties.4,5 Within the medical training community, criticisms exist regarding the OCE and certification process in general. Most frequently, these criticisms cite cost and question the exam’s necessity and benefit to candidates.8

To evaluate the certification process, ABEM in 2021 launched its multiyear Becoming Certified Initiative (BCI). This initiative led to a complete overhaul of the final step of the certification process, based on stakeholder feedback (stakeholders included practicing physicians, educators, EM organizations, and employers). Feedback included the need for a more flexible exam that’s more meaningful to examinees, as well as a need to assess “non-AI replaceable” skills.9,10

Changes to the Certifying Exam
Exam Content
The new certifying exam will be based around 2 different case types: clinical care cases and observed structured clinical examination (OSCE) cases.

Clinical care cases include sessions where candidates “converse with an examiner to show how they prioritize patient care, assess their adaptability to unexpected clinical changes, and interact with various sources of information.”11 In prioritization cases, examinees may be presented with a tracking board and asked to triage multiple patients arriving with conditions and injuries of various acuities. In troubleshooting cases, candidates are expected to respond to unexpected lab or diagnostic findings and pivot their care appropriately. Cases may also involve difficult conversations, such as breaking bad news, to assess patient-centered communication skills.12

New to the certification process will be OSCEs, which involve standardized patients (SPs) in interactive clinical scenarios. OSCEs evaluate the above competencies, including technical and procedural skills.11 For procedural cases, ABEM emphasized that tested skills will be “bread and butter” EM competencies such as airway management, joint arthrocentesis, and central line placement. To prevent applicants with better simulation training resources from having an advantage, no high fidelity simulation scenarios will be used.12

Logistics of Exam Day
Each testing session will be approximately 3 hours.12 For clinical cases, each case will be 15 minutes in length, with 4 cases per session. For the OSCEs, each case will be 10-15 minutes, with 5 stations.12 Candidates will be able to schedule a morning or afternoon session during a 4- to 5-day testing week, with 9 test administration sessions per year to provide greater scheduling flexibility compared to the current OCE.13

The certifying exam is to be held exclusively at the AIME Center in Raleigh, NC. In its search for an appropriate venue, ABEM cited the need for a testing venue with simulation and procedural assessment capabilities, future integration of virtual reality, and access to a diverse, trained pool of standardized patients.14 In a presentation to EMRA residency representatives, ABEM President Ramon Johnson, MD, MBA, noted that the AIME Center is an ideal site because it is anassessment center as opposed to a primary simulation center.13,14

The AIME Center already hosts the American Board of Anesthesiology's APPLIED exam, which is 1 component of the anesthesiology board certification process.15 The APPLIED exam has 8-minute OSCEs assessing a variety of clinical procedural skills and result interpretations, including cardiac and pulmonary ultrasounds, nerve blocks, and vascular cannulation. While it’s unclear what components will translate into ABEM’s new exam, this helps elucidate how the AIME Center may contribute to ABEM’s new assessment goals.16

Exam Philosophy, Preparation, Scoring
To help candidates prepare for the new exam, ABEM is making videos with sample cases and exam center walk-throughs. ABEM also plans to share rubrics for each case type. Scoring standards will be based on references set by practicing board-certified emergency physicians; there is no intention to grade the exam on a curve. To decrease potential biases between examiner and examinee, the OSCEs will have objective criteria with multiple reviewers. Examiners will score in-person for procedural cases and asynchronously for other cases.

According to ABEM, this exam is designed to better assess clinical training received in residency.

ABEM Exam Secondary Art.jpg

Stakeholder Concerns, Responses to Criticisms
Shortly after ABEM’s initial announcement regarding exam changes, EMRA released a statement in response, citing multiple concerns — including lack of significant stakeholder input from EMRA and its members, cost, accessibility, undue burden on under-represented in medicine (URiM) individuals, and more.17 In light of newly disseminated information and continued ABEM announcements, the authors of this article would like to further raise the following concerns, expressed with the interests of EMRA members in mind:

Addressing the Root Cause
The utility of a 2nd oral exam has been questioned when a written qualifying exam also exists in both the current and newly proposed ABEM certification processes.8 ABEM suggests that the OCE tests different aspects of clinical competency than the QE.5 Positive performance on the QE has been associated with positive performance on the OCE based on 1 study,18 indicating possible redundancy between the exams, despite their differences. ABEM, however, argues that the 2 exams vary enough to necessitate both. It is worth noting that the current OCE typically has a pass rate around 90%,13 near that of the now-defunct Step 2 Clinical Skills exam.19

ABEM’s response to these concerns thus far has focused on the fact that residency training varies from program to program and even within a program from year to year.13 Given the recent surge in EM residency programs and record-high numbers of EM residency graduates, ABEM cites the need for rigorous assessment to a national standard.1,2ABEM has acknowledged that regulating residency program quality falls under jurisdiction of the ACGME. However, ABEM also notes that both organizations have co-authored the same milestones and knowledge, skills, & abilities (KSAs) under which residents are regularly assessed.20

Rather than an oral/in-person exam of questionable utility, perhaps regulation and standardization among residency programs should be more closely addressed on an individual, program-level basis. A potential intervention could include more frequent site visits to better understand program training and performance. Assessing soft skills of triaging, board management, and communication in addition to procedures at this level, as opposed to at the end of training, would serve 2 purposes:

  1. Allow programs to improve training/instruction on areas of identified, common deficiencies among their residents
  2. Allow for intervention at the individual level at a time in training when changes can be made more easily, as opposed to after residency when new attendings may have less leniency in practice and less structured professional support.

Cost
Becoming a board-certified emergency physician is vital to securing a job in certain markets and is the main driver of hiring, according to employers in the field.1,2 Presently, the entire certification process (with the current OCE) costs a minimum of $2,645 — and up to $3,665 if registering during “late” periods.3,4

With the new in-person exam, costs are expected to increase significantly, given travel and lodging needs alone. Costs could increase even more due to simulation- and testing center-related needs (although ABEM “does not anticipate significant changes in the aggregate costs for initial certification,” according to its Certifying Exam FAQs document).

From a resident’s perspective, it is difficult to justify spending thousands of dollars on plane tickets, food, lodging, and the test itself when an evidence-backed virtual option exists. The brunt of the cost of an in-person exam falls on newly minted attending physicians, many of whom are unlikely to have a cushion of savings and who also may suddenly have higher loan repayments upon residency graduation. As previously noted by EMRA, this change disproportionately affects URiM candidates.17 When stakeholders inquired whether ABEM was considering further individualized cost-offsetting measures (such as scholarships, for those with extenuating financial circumstances), no clear answer was provided.13 In response to concerns about cost, Dr. Johnson noted that anesthesiology candidates taking the APPLIED exam at the AIME Center found travel and lodging “affordable and accessible.”13

In addition to expenditures related directly to testing, applicants must address various additional monetary and non-monetary costs. For instance, with only one location (Raleigh, NC) available for the oral exam, many physicians will face the added burden of time and resources needed for travel, as well as the inconvenience of having to coordinate home and work needs during their absence. Examples of hardships:

  • Added travel time or even missed exam days due to flight/travel delays
  • Limited travel options from rural settings
  • Finding child care (including overnight) while away testing
  • Filling gaps in work coverage, which may cut into a new physician’s already limited personal/vacation days

Additionally, no clear plan for in-person testing exists at this time for individuals serving abroad in uniformed services or other capacities.13

Conclusion
The financial, equitable, and logistical implications of a new, in-person ABEM certifying exam as planned — especially one that replaces the current virtual OCE format — warrants further consideration and discussion with the most affected stakeholders: trainees and early-career physicians.

We, article authors and leaders of the EMRA Education Committee, will continue to update EMRA members as more information and details are released. Updates and clarifications to ABEM’s current plans may affect our discussion above and expressed opinions.

Editor’s note: The thoughts and opinions expressed in this article represent only those of the authors as individuals. They do not represent the positions or opinions of EMRA as an organization, nor do they represent those of the authors’ institutions.


References

  1. Becoming Certified Initiative Summary of Feedback. American Board of Emergency Medicine. (Retrieved 2024, January 10). https://www.abem.org/public/docs/default-source/default-document-library/BCI-Summary-of-Feedback.pdf
  2. Becoming Certified Initiative Key Findings. American Board of Emergency Medicine. (Retrieved 2024, January 10). https://www.abem.org/public/docs/default-source/default-document-library/BCI-Key-Findings.pdf
  3. American Board of Emergency Medicine. (n.d.). Qualifying exam. ABEM. https://www.abem.org/public/become-certified/qualifying-exam
  4. American Board of Emergency Medicine. (n.d.). Oral Exam. Oral exam. https://www.abem.org/public/become-certified/oral-exam
  5. Virtual Oral Exam FAQ. American Board of Emergency Medicine. (Retrieved January 1, 2024) https://www.abem.org/public/docs/default-source/policies-faqs/virtual-oral-exam-faqs.pdf.
  6. American Board of Emergency Medicine. (2021, February 08). ABEM Committed to Maintaining Certification Standards. ABEM News. Retrieved from https://www.abem.org/public/news-events/abem-news/2021/02/08/abem-committed-to-maintaining-certification-standards. Penned by Mary Nan Mallory, M.D., M.B.A.
  7. American Board of Emergency Medicine. (2021, December 15). The Virtual Oral Exam: ABEM Pivots During the Pandemic to Help Physicians Achieve Certification. ABEM News. Retrieved from https://www.abem.org/public/news-events/abem-news/2021/12/15/the-virtual-oral-exam-abem-pivots-during-the-pandemic-to-help-physicians-achieve-certification.
  8. Schwartz, J., & Babineau, M. (2022, January 27). Quarantine the Oral Boards. ACEP Now. https://www.acepnow.com/article/quarantine-the-oral-boards/
  9. American Board of Emergency Medicine. (n.d.). BCI framework. https://www.abem.org/public/docs/default-source/default-document-library/bci-framework.pdf
  10. American Board of Emergency Medicine. (n.d.). Becoming Certified Task Force . ABEM Becoming Certified Initiative | Emergency Medicine Certification. https://www.abem.org/public/become-certified/certifying-exam/becoming-certified-initiative
  11. American Board of Emergency Medicine. (n.d.). Certifying Exam. Certifying Exam | Emergency Medicine Certification. https://www.abem.org/public/become-certified/certifying-exam
  12. American Board of Emergency Medicine. (2024). Certifying Exam - Informational Webinar.
  13. Johnson, R. (2024). EMRA Representative Council Meeting - “A Conversation with ABEM” Via Zoom. Emergency Medicine Residency Association.
  14. Why Raleigh? American Board of Emergency Medicine. (Retrieved 2024, January 10). https://www.abem.org/public/docs/default-source/default-document-library/for-website_why-raleigh.pdf?sfvrsn=c4b1d3f4_1
  15. APPLIED Exam. The American Board of Anesthesiology. (n.d.). https://www.theaba.org/certification-exam-type/applied-exam/
  16. APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline. (2021). The American Board of Anesthesiology. https://www.theaba.org/wp-content/uploads/2022/12/OSCE_Content_Outline.pdf
  17. EMRA has Your Back: Statement on New ABEM Certifying Exam (2024, January 10).Emergency Medicine Residency Association. https://www.emra.org/be-involved/be-an-advocate/working-for-you
  18. Gorgas DL, Calderon Y, Carter WA, et al. The correlation between performance on the American Board of Emergency Medicine (ABEM) qualifying and oral certifying examinations. Acad Emerg Med. 2024; 31: 91-93. doi:10.1111/acem.14780
  19. Murphy, B. (2021, February 4). USMLE Step 2 CS Canceled: What it Means for Medical Students. American Medical Association. https://www.ama-assn.org/medical-students/usmle-step-1-2/usmle-step-2-cs-canceled-what-it-means-medical-students
  20. Emergency Medicine Milestones & KSAs. (n.d.). American Board of Emergency Medicine. https://www.abem.org/public/resources/emergency-medicine-milestones-ksas

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